Community Hospital Onaga Ltcu
206 Grand Avenue, St Marys, KS 66536
Community Hospital Onaga Ltcu is a nursing home in St Marys, Kansas. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 5 of 5CMS overall star rating
- 5 of 5CMS health inspection star rating
- 5 of 5CMS staffing star rating
- 4 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (785) 437-2286
- Last standard health inspection
- October 31, 2024 (2 years ago)
- Certified beds
- 26
- Residents per day, on average
- 22.6
- Ownership type
- Non profit - Corporation
- Legal business name
- Legal Business Name Not Available
- Chain
- Not listed by CMS
- Takes part in
- Medicaid
Fewer health citations than the Kansas average (9 vs 28).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
CMS update of February 25, 2026
Star rating
The CMS quality measures star rating changed from 3 of 5 to 5 of 5.
CMS update of November 20, 2025
Staffing
Total nurse staffing reported to CMS went from 6.0 to 5.2 hours per resident per day.
CMS update of July 30, 2025
Star rating
The CMS quality measures star rating changed from 5 of 5 to 3 of 5.
CMS update of April 30, 2025
Star rating
The CMS staffing star rating changed from 4 of 5 to 5 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 5 of 5.
CMS update of February 26, 2025
Star rating
The CMS staffing star rating changed from 5 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Staffing
Total nurse staffing reported to CMS went from 6.0 to 5.4 hours per resident per day.
3 citations
Health inspection on October 31, 2024
CMS lists this as a standard inspection.
Citation F0636. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
CMS lists it as corrected on November 18, 2024.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on November 18, 2024.
Citation F0849. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
CMS lists it as corrected on November 18, 2024.
2 citations
Fire safety inspection on October 31, 2024
CMS lists this as a standard inspection.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on December 23, 2024.
CMS has cited this home for K0345 3 times since 2021.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on December 23, 2024.
CMS has cited this home for K0353 3 times since 2021.
CMS update of October 30, 2024
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
CMS update of July 31, 2024
Staffing
Total nurse staffing reported to CMS went from 6.2 to 5.6 hours per resident per day.
CMS update of April 25, 2024
Star rating
The CMS overall star rating changed from 4 of 5 to 5 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 5 of 5.
CMS update of January 31, 2024
Star rating
The CMS overall star rating changed from 5 of 5 to 4 of 5.
Star rating
The CMS staffing star rating changed from 5 of 5 to 1 of 5.
5 citations
Health inspection on June 19, 2023
CMS lists this as a standard inspection.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on July 5, 2023.
Citation F0744. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
CMS lists it as corrected on July 5, 2023.
Citation F0756. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on July 5, 2023.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on July 5, 2023.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
CMS lists it as corrected on July 5, 2023.
5 citations
Fire safety inspection on June 19, 2023
CMS lists this as a standard inspection.
Citation K0161. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Use approved construction type or materials.
CMS lists it as corrected on August 12, 2023.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on August 12, 2023.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on August 12, 2023.
Citation K0353. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on August 12, 2023.
Citation K0355. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on August 12, 2023.
CMS has cited this home for K0355 2 times since 2021.
1 citation
Health inspection on December 21, 2021
CMS lists this as a standard inspection.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on January 19, 2022.
13 citations
Fire safety inspection on December 21, 2021
CMS lists this as a standard inspection.
Citation K0222. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
CMS lists it as corrected on February 28, 2022.
Citation K0324. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on February 28, 2022.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on February 28, 2022.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on February 28, 2022.
Citation K0355. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on February 28, 2022.
Citation K0372. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on February 28, 2022.
Citation K0916. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have a battery powered remote alarm panel in a location accessible by operating personnel.
CMS lists it as corrected on February 28, 2022.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on February 28, 2022.
Citation K0920. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on February 28, 2022.
Citation K0321. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on February 28, 2022.
Citation K0363. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on February 28, 2022.
Citation K0902. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Meet requirements for the installation and maintenance of medical gas and medical vacuum systems.
CMS lists it as corrected on February 28, 2022.
Citation K0908. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
CMS lists it as corrected on February 28, 2022.
Questions
When was Community Hospital Onaga Ltcu last inspected?
CMS lists October 31, 2024 as the date of its most recent standard health inspection.
How many citations (violations) does Community Hospital Onaga Ltcu have?
CMS lists 9 health citations since December 21, 2021. CMS also calls these deficiencies.
Has Community Hospital Onaga Ltcu been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Community Hospital Onaga Ltcu?
Its CMS overall star rating is 5 of 5.
Is Community Hospital Onaga Ltcu a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.